Anesthesia for gender-affirming surgery: a practical review.

PURPOSE OF REVIEW: Gender-affirming surgery (GAS) is an effective, well studied, and often necessary component of gender-affirming care and mitigation of gender dysphoria for transgender and gender-diverse (TGD) individuals. GAS is categorized as chest surgeries, genitourinary surgeries, facial feminization/masculinization, and vocal phonosurgery. Despite increased incidence of GAS during recent years, there is a gap in knowledge and training on perioperative care for TGD patients. RECENT FINDINGS: Our review discusses the relevant anesthetic considerations for the most common GAS, which often involve highly specialized surgical techniques that have unique implications for the anesthesia professional. SUMMARY: Anesthesiology professionals must attend to the surgical and anesthetic nuances of various GAS procedures. However, as many considerations are based on common practice, research is warranted on anesthetic implications and outcomes of GAS.

Racial Disparities in Compensation Among US Anesthesiologists: Results of a National Survey of Anesthesiologists.

BACKGROUND: A racial compensation disparity among physicians across numerous specialties is well documented and persists after adjustment for age, sex, experience, work hours, productivity, academic rank, and practice structure. This study examined national survey data to determine whether there are racial differences in compensation among anesthesiologists in the United States. METHODS: In 2018, 28,812 active members of the American Society of Anesthesiologists were surveyed to examine compensation among members. Compensation was defined as the amount reported as direct compensation on a W-2, 1099, or K-1, plus all voluntary salary reductions (eg, 401[k], health insurance). Covariates potentially associated with compensation were identified (eg, sex and academic rank) and included in regression models. Racial differences in outcome and model variables were assessed via Wilcoxon rank sum tests and Pearson's χ 2 tests. Covariate adjusted ordinal logistic regression estimated an odds ratio (OR) for the relationship between race and ethnicity and compensation while adjusting for provider and practice characteristics. RESULTS: The final analytical sample consisted of 1952 anesthesiologists (78% non-Hispanic White). The analytic sample represented a higher percentage of White, female, and younger physicians compared to the demographic makeup of anesthesiologists in the United States. When comparing non-Hispanic White anesthesiologists with anesthesiologists from other racial and ethnic minority groups, (ie, American Indian/Alaska Native, Asian, Black, Hispanic, and Native Hawaiian/Pacific Islander), the dependent variable (compensation range) and 6 of the covariates (sex, age, spousal work status, region, practice type, and completed fellowship) had significant differences. In the adjusted model, anesthesiologists from racial and ethnic minority populations had 26% lower odds of being in a higher compensation range compared to White anesthesiologists (OR, 0.74; 95% confidence interval [CI], 0.61-0.91). CONCLUSIONS: Compensation for anesthesiologists showed a significant pay disparity associated with race and ethnicity even after adjusting for provider and practice characteristics. Our study raises concerns that processes, policies, or biases (either implicit or explicit) persist and may impact compensation for anesthesiologists from racial and ethnic minority populations. This disparity in compensation requires actionable solutions and calls for future studies that investigate contributing factors and to validate our findings given the low response rate.

COVID-19 in the Cancer Patient.

The novel coronavirus disease 2019 (COVID-19) was first reported in China in December 2019. Since then, it has spread across the world to become one of the most serious life-threatening pandemics since the influenza pandemic of 1918. This review article will focus on the specific risks and nuanced considerations of COVID-19 in the cancer patient. Important perioperative management recommendations during this outbreak are emphasized, in addition to discussion of current treatment techniques and strategies available in the battle against COVID-19.

Institution of Monthly Anesthesia Quality Reports Does Not Reduce Postoperative Complications despite Improved Metric Compliance.

While quality programs have been shown to improve provider compliance, few have demonstrated conclusive improvements in patient outcomes. We hypothesized that there would be increased metric compliance and decreased postoperative complications after initiation of an anesthesiology quality improvement program at our institution. We performed a retrospective study of all adult inpatients having anesthesia for a twelve-month period that spanned six months before and after program implementation. The primary outcome was the rate of complications in the post-implementation period. Secondary outcomes included the change in proportion of complications and compliance with quality metrics. We studied a total of 9620 adult inpatient cases, subdivided into pre- and post-implementation groups (4832 vs 4788.) After multivariate model adjustment, the rate of any complication (our primary outcome) was not significantly changed (32% to 31%; adjusted P = 0.410.) Of the individual complications, only wound infection (2.0% to 1.5%; adjusted P = 0.020) showed a statistically significant decrease. Statistically and clinically significant increases in compliance were seen for the BP-02 Avoiding Monitoring Gaps metric (81% to 93%, P < 0.001), both neuromuscular blockade metrics (NMB-01 76% to 91%, P < 0.001; NMB-02 95% to 97%, P = 0.006), both tidal volume metrics (PUL-01 84% to 93%, P < 0.001; PUL-02 30% to 45%, P < 0.001), and the TEMP-02 Core Temperature Measurement metric (88% to 94%, P < 0.001). Implementation of a comprehensive quality feedback program improved metric compliance but was not associated with a change in postoperative complications.

The Perioperative Care of the Transgender Patient.

An estimated 25 million people identify as transgender worldwide, approximately 1 million of whom reside in the United States. The increasing visibility and acceptance of transgender people makes it likely that they will present in general surgical settings; therefore, perioperative health care providers must develop the knowledge and skills requisite for the safe management of transgender patients in the perioperative setting. Extant guidelines, such as those published by the World Professional Association for Transgender Health and the University of California San Francisco Center of Excellence for Transgender Health, serve as critical resources to those caring for transgender patients; however, they do not address their unique perioperative needs. It is essential that anesthesia providers develop the knowledge and skills necessary for safely managing transgender patients in the perioperative setting. This review provides an overview of relevant terminology, the imperative for the provision of culturally sensitive care, and guidelines for preoperative, intraoperative, and postoperative management of the transgender patient.

Interrater variability in ASA physical status assignment: an analysis in the pediatric cancer setting.

BACKGROUND: The American Society of Anesthesiologists (ASA) physical status is a universal classification system that helps clinicians to categorize their patients preoperatively. However, there is a lack of both inter-rater and intra-rater reliability among clinicians for the ASA physical status classification. Our study focuses on testing these reliabilities within pediatric anesthesia providers in the cancer setting. METHODS: In our retrospective observational study, a total of 1177 anesthesia records were reviewed. The cohort included all pediatric patients (≤ 18 years old) diagnosed with either retinoblastoma or neuroblastoma who had two or more anesthesia procedure within a 14-day time period. RESULTS: Overall, the ASA physical status score among two different anesthesia providers for the same patient treated at different times had very little inter-rater reliability, κ = - 0.042 (95% CI - 0.17; 0.09). Of the 1177-patient anesthesia records, only 25% had two or more ASA physical status score assigned by the same anesthesiologist within a 14-day time period. There was moderate intra-rater reliability κ = 0.48 (95% CI 0.29; 0.68) for patients who were assigned an ASA physical status score by the identical anesthesia provider at different times points within a 14 day period. CONCLUSION: In contrast to observations in earlier studies, findings indicate poor agreement in inter-rater reliability. Although there was moderate agreement in intra-rater reliability, one would expect to find stronger, even perfect, intra-rater reliability. These findings suggest the need to develop a specific physical status classification system directed toward patients with a systemic illness such as cancer in both young and adult patients.

Anesthetic Management and Neuromonitoring in a Patient with Very Long-Chain Acyl-Coenzyme A Dehydrogenase Deficiency Undergoing Scoliosis Surgery: A Case Report and Review of Literature.

Patients with very long-chain acyl-CoA dehydrogenase deficiency (VLCADD) are prone to hypoglycemia and clinical decompensation when metabolic demands of the body are not met. We present a pediatric patient with VLCADD who underwent a posterior spinal fusion for scoliosis requiring intraoperative neurophysiology monitoring. Challenges included minimization of perioperative metabolic stressors and careful selection of anesthetic agents since propofol-based total intravenous anesthesia (TIVA) was contraindicated due to its high fatty acid content. This case is unique due to the sequential use of inhaled anesthetics after TIVA to allow for a rapid wakeup and immediate postoperative physical exam. Additionally, intraoperative neuromonitoring in the setting of VLCADD has not been reported in the literature. With communication among anesthesia, surgery, and neuromonitoring teams before and during the operation, the patient successfully underwent a major surgery without complications. This trial is registered with NCT03808077.

Mobitz II Second-Degree Heart Block During Total Hip Arthroplasty: ACase Report.

Spontaneous intraoperative development of Mobitz II second-degree atrioventricular block is a rare event which requires decisive action on the part of anesthesiologists and anesthetists. Given that this arrhythmia can be fatal if not properly managed, it is imperative that every practitioner know how it should be managed. Currently, there is a lack of literature discussing what to expect when a patient develops this complication and what the best management strategies are. This case report describes the unexpected development of Mobitz II second-degree atrioventricular block in an elderly patient with no prior history of conduction abnormalities undergoing total hip arthroplasty and how it was managed during the perioperative period to avoid morbidity or mortality. It includes a proposed management algorithm as an easy to use guide in the management of similar clinical scenarios. While this algorithm should be familiar to anesthesiologists and experienced anesthetists, it can serve as a reference in critical situations, and may help in educating trainees.

Standardizing the Dosage and Timing of Dexamethasone for Postoperative Nausea and Vomiting Prophylaxis at a Safety-Net Hospital System.

BACKGROUND: A single dose of dexamethasone is routinely given during general anesthesia for postoperative nausea and vomiting (PONV) prophylaxis, although the exact dosage and timing of administration may vary between practitioners. The authors aimed to standardize the dosage and timing of this medication when given to adult patients undergoing general anesthesia for elective surgery. METHODS: Baseline data for 7,483 preintervention cases were analyzed. The researchers attempted to use a standard dose of 8 to 10 mg induction of anesthesia, which, based on a literature review, was effective for PONV prophylaxis, had a similar safety profile as a 4 to 5 mg dose (including in diabetic patients), and may confer additional benefits such as improved prophylaxis and quality of recovery. The interventions included standardizing the medication concentration vials, altering electronic health record quick-select button options, simplifying the intraoperative charting process, and educating the anesthesia providers. The research team then tracked compliance with the standard of care for 2,167 cases after the interventions. RESULTS: Overall compliance with the standard of care increased from 21.2% preintervention to 53.7% postintervention. The number of patients not receiving dexamethasone was reduced from 29.7% to 19.4%. Patients receiving a compliant dose at a noncompliant time increased from 16.3% to 23.8%. Postanesthesia care unit antiemetic administration also decreased after the interventions. CONCLUSION: This study showed improvements in compliance with the dosage of medication with the interventions. However, compliance with the timing of administration remains challenging.

Laparoscopic transversus abdominis plane block reduces postoperative opioid requirements after laparoscopic cholecystectomy.

BACKGROUND: Surgeons directly contribute to the over-prescription of opioids. Alternative postoperative pain management strategies are necessary to reduce opioid dispensation and combat the opioid epidemic. We set out to examine the effectiveness of a laparoscopic transversus abdominis plane block on reducing opioid requirements after laparoscopic cholecystectomy. METHODS: In a retrospective cohort analysis, we compared opioid naïve patients who underwent an elective, outpatient laparoscopic cholecystectomy with a transversus abdominis plane block with patients who underwent a laparoscopic cholecystectomy alone between January 2018 and June 2021 at a single institution. Patient characteristics, perioperative pain scores, and postoperative analgesic requirements were compared between cohorts. RESULTS: There were 200 patients included in the study (laparoscopic cholecystectomy with a transversus abdominis plane block, n = 100; laparoscopic cholecystectomy alone, n = 100). The average postoperative pain scores in the postanesthesia care unit were equivalent between the groups (laparoscopic cholecystectomy with a transversus abdominis plane block = 3.39 versus laparoscopic cholecystectomy alone = 4.17, P = .12), with the mean postanesthesia care unit opioid requirements significantly lower in patients receiving laparoscopic cholecystectomy with a transversus abdominis plane block (12.1 vs 20.4 oral morphine equivalents, P < .001). Patients receiving laparoscopic cholecystectomy with a transversus abdominis plane block were prescribed fewer opioids on discharge (mean 77.5 vs 92.9 oral morphine equivalents, P < .05) and reported using a lower proportion of their opioid prescription at follow-up (83.2% vs 100%, P < .001). Of the patients receiving laparoscopic cholecystectomy with a transversus abdominis plane block, 65% reported using over-the-counter pain medications compared with 82% of patients receiving laparoscopic cholecystectomy alone (P < .001). CONCLUSION: Performing a laparoscopic transversus abdominis plane block during elective laparoscopic cholecystectomy is a safe and effective strategy to reduce postoperative opioid requirements for the treatment of acute postoperative pain.

Perioperative Oncology Health Care Providers and Transgender Health: A Single-Institution Survey to Gauge Attitudes, Knowledge, Behaviors, and Education.

Purpose: Patients identifying as transgender report that a lack of access to providers with trans-specific medical knowledge represents one of the largest barriers to equitable health care access. Through an institutional survey, we assessed and analyzed the attitudes, knowledge, behaviors, and education of perioperative clinical staff when caring for transgender patients with cancer. Methods: A web-based survey was distributed to 1100 perioperative clinical staff at the National Cancer Institute (NCI)-Designated Comprehensive Cancer Center in New York City between January 14, 2020, and February 28, 2020, and received 276 responses. The survey instrument consisted of 42 nondemographic questions about attitudes, knowledge, behaviors, and education regarding transgender health care and 14 demographic questions. Questions were presented as a mix of Yes/No, free text response, and a 5-point Likert scale. Results: Certain demographic groups (younger, lesbian, gay, or bisexual [LGB], fewer years employment at the institution) held more favorable attitudes toward the transgender population and were more knowledgeable regarding their health needs. Respondents underreported the rates of mental illness and risk factors for cancer like HIV and substance use among the transgender population. A greater proportion of respondents identifying as LGB endorsed witnessing an interaction wherein a colleague exhibited attitudes/beliefs about the transgender population that were barriers to care. Only 23.2% of respondents were ever trained on the health needs of transgender patients. Conclusion: There is a need for institutions to assess the cultural competency of perioperative clinical staff toward transgender health, especially within certain demographics. This survey may inform quality education initiatives to eliminate biases and knowledge gaps.

Pre-appendectomy hyponatremia is associated with increased rates of complicated appendicitis.

Background: Acute appendicitis is one of the most common surgical emergencies worldwide. Preoperative assessment of the risk of complicated appendicitis may aid in treatment planning. We sought to investigate the association between pre-appendectomy hyponatremia and diagnosis of complicated appendicitis. Methods: The TriNetX platform, a federated health research network that aggregates de-identified electronic health record data of over 90 million patients across the United States, was queried for patients who underwent appendectomy starting January 2019 and who had at least one sodium value from the preoperative period. The study population was stratified into three age groups: pediatric (age < 18), adult (age 18-64), and older adult (age ≥ 65). These groups were subdivided into patients with preoperative hyponatremia (<135 mmol/L) and normonatremia (135-145 mmol/L). Results: Among the 61,245 patients who met inclusion criteria, 17,546 were included for analysis following propensity score matching. The odds of complicated appendicitis were highest in pediatric patients (age < 18) with pre-appendectomy hyponatremia (odds ratio [OR] = 2.91, 95 % CI [2.53, 3.35]). Patients age 18-64 and aged ≥ 65 with preoperative hyponatremia also demonstrated increased odds of a complicated appendicitis diagnosis, but to a lesser extent (OR = 2.11, 95 % CI [1.92, 2.32] (OR = 1.49, 95 % CI [1.25, 1.77], respectively). Conclusions: In a large analysis of matched patients with acute appendicitis, we found an association between immediate preoperative hyponatremia and complicated appendicitis. Future studies are indicated to further evaluate the role of hyponatremia as a potential diagnostic marker for complicated appendicitis in all age groups. Key message: This study suggests a role of hyponatremia as one of multiple variables to incorporate into future clinical decision tools for complicated acute appendicitis.

Discharge prescribing of enteral opioids in opioid naïve patients following non-surgical intensive care: A retrospective cohort study.

PURPOSE: To estimate the incidence of new prescription of enteral opioids on hospital discharge in opioid naïve, non-surgical, critically ill patients and evaluate the risk factors associated with such occurrence. METHODS: Using hospital-wide and ICU databases, we retrospectively identified all patients (≥ 18 years old) who were admitted to the 20-bed adult ICU of Memorial Sloan Kettering Cancer Center (MSKCC) between July 1, 2015 and April 20, 2020. Patients' electronic medical records (EMR) were retrieved and patient demographics, peri-ICU admission data were captured and analyzed. RESULTS: During the study period, a total of 3755 opioid naïve patients were admitted to the ICU and 848 patients met the inclusion criteria. Among these, 346 (40.8%) patients were discharged with a new opioid prescription. Age at ICU admission, preadmission use of benzodiazepine, and antidepressants, a diagnosis of sepsis, and use of mechanical ventilation, antidepressants or, opioid infusion for greater than 4 h during the ICU stay, hospital length of stay (LOS), and days between ICU discharge and hospital discharge were independently associated with increased odds of a new opioid prescription. CONCLUSIONS: A significant proportion of opioid naïve non-surgical ICU survivors receive a new opioid prescription on hospital discharge.

Perioperative corneal injury: An unseen casualty of COVID-19.

Introduction: This study is the first to reveal an increased incidence in perioperative corneal injuries during the COVID era and should alert clinicians to this observation. This study could inform investigations into practice or patient factors that changed as a result of the COVID pandemic. We were aware of several adverse corneal injury reports during COVID and as a result did a formal IRB approved retrospective review to see if corneal injuries were more common during that period. Methods: This is a retrospective cross-sectional observational study based on the hospital reporting of corneal injuries in the peri-operative time-period during the COVID pandemic. Comparison to known incidence of corneal injuries from the same institution in the pre COVID era were made. The objective was to examine if there were increased peri-operative corneal injuries during the COVID pandemic compared to other time points at our institution. Results: All corneal injury event reports were aggregated for the time period including January 1, 2015 through April 30, 2021. Data include all patients who underwent anesthesia for any procedure at all sites within the hospital system. Corneal injury rates (in lieu of total number of events) were utilized to account for variation in perioperative volume. Using Poisson regression, corneal injury rates were significantly higher after March 2020 compared to the other time points. Alternatively, RISQ reporting rates were significantly lower after March 2020 compared to other time points. Conclusions: This study reveals an increased incidence in perioperative corneal injuries during the COVID era and should alert clinicians to this observation. This study may inform investigations and may ultimately drive processes that could mitigate preventable causes of perioperative corneal injury.

Perioperative considerations for cancer patients with obesity: A narrative review.

Cancer in patients with obesity has become increasingly common throughout much of the world. Based on our experiences in a specialized cancer center, we have developed a set of standards and expectations that should streamline the surgical journey for this patient population. These recommendations should inform the perioperative management of oncology patients with obesity and help raise awareness of this critical and under-discussed topic.